Does your doctor have a protocol to discover and treat dehydration? Or is your doctor winging it? With NO PROTOCOL your doctor is effectively killing off salvageable neurons. Charging $1000 a dead neuron sounds about right.
Frequency, Risk Factors, and Prognosis of Dehydration in Acute Stroke
Elena Cortés-Vicente, 
Daniel Guisado-Alonso, Raquel Delgado-Mederos, Pol Camps-Renom, Luis Prats-Sánchez, Alejandro Martínez-Domeño and 
Joan Martí-Fàbregas*- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
Objective: To determine the frequency, risk factors, and impact on the outcome of dehydration after stroke.
Methods: In this cross-sectional
observational study, we included prospectively and consecutively
patients with ischemic and hemorrhagic stroke. The serum Urea/Creatinine
ratio (U/C) was calculated at admission and 3 days after the stroke.
Dehydration was defined as U/C>80. Patients were treated in
accordance with the standard local hydration protocol. Demographic and
clinical data were collected. Neurological severity was evaluated at
admission according to the NIHSS score; functional outcome was assessed
with the modified Rankin scale score (mRS) at discharge and 3 months
after the stroke. Unfavorable outcome was defined as mRS > 2.
Results: We evaluated 203 patients;
78.8% presented an ischemic stroke and 21.2% a hemorrhagic stroke. The
mean age was 73.4 years ±12.9; 51.7% were men. Dehydration was detected
in 18 patients (8.9%), nine patients at admission (4.5%), and nine
patients (4.5%) at 3 days after the stroke. Female sex (OR 3.62, 95%CI
1.13–11.58, p = 0.03) and older age (OR 1.05, 95%CI 1–1.11, p
= 0.048) were associated with a higher risk of dehydration. Dehydration
was significantly associated with an unfavorable outcome at discharge
(OR 5.16, 95%CI 1.45–18.25, p = 0.011), but the association was not significant at 3 months (OR 2.95, 95%CI 0.83–10.48, p = 0.095).
Conclusion: Dehydration is a treatable
risk factor of a poor functional outcome after stroke that is present in
9% of patients. Females and elders present a higher risk of
dehydration.
Introduction
The clinical guidelines state that dehydration after stroke results in a poorer vital and functional prognosis (1–4).
Dehydration increases hemoconcentration and blood viscosity and
decreases blood pressure(meaning you have less oxygen being delivered to your brain increasing the dead neuron rate in your penumbra), factors that may worsen the effects of brain
ischemia (5),
resulting in greater brain damage, and more severe symptoms.
Dehydration is related also with a higher risk of complications, such as
venous thrombosis. Among other factors, stroke patients may be
predisposed to dehydration because of decreased oral intake of water due
to dysphagia (6) or low level of consciousness. Stroke occurs more frequently in the elderly, and dehydration is common in these patients (7).
Dehydration is important also because of its economic impact, as
dehydration at admission is associated with higher admission costs in
acute ischemic stroke (8).
There is substantial variation in hydration status definition and diagnostic approach to dehydration (9). The blood Urea/Creatinine ratio (U/C) (10, 11), the blood urea nitrogen/Creatinine ratio (BUN/C) (6, 8, 12) and plasma osmolality (13)
have been used to detect dehydration. Multi-frequency bioelectrical
impedance has also been tested, but appeared ineffective to diagnose
dehydration correctly after stroke (14).
These studies suggested that dehydration after stroke is a prevalent
phenomenon, with a frequency around 60% measured with de U/C ratio (10) and around 53% with the BUN/C ratio (6), and that it is associated with a poor prognosis (8, 10, 12, 13).
However, these studies are retrospective and did not include a
follow-up evaluation. Thus, it is still unclear if dehydration
significantly influences outcome.
Our aim was to determine the frequency and risk factors
of dehydration after acute stroke, and its effects on the outcome at
discharge and 3 months after stroke, using a blood biomarker of
dehydration as a diagnostic tool.
Materials and Methods
Patients
This is a cross-sectional observational study of patients
prospectively and consecutively included during a 10-month period. This
period of time was estimated to include 185 patients, the sample size
needed for an estimated proportion of 62% (10),
a 95% confidence level, and a desired precision of 7%. All patients had
an ischemic or hemorrhagic stroke, confirmed by neuroimaging techniques
(CT or MRI). Patients under 18 years old, admitted >72 h after
stroke onset and with a previous modified Rankin scale score (mRS) >2
were excluded.
Clinical Evaluation
Patients were evaluated by a neurologist at admission, at
discharge and 3 months after stroke. Assessment included evaluation of
stroke severity according to the National Institute of Health Stroke
Scale (NIHSS) score and functional evaluation according to the mRS
score. Investigators were blinded to the U/C ratio results. Unfavorable
outcome was defined as mRS > 2. The functional evaluation of the
patients was assessed during face-to-face interviews 3 months after
stroke. If a face-to-face interview was not possible, the data were
obtained by a phone interview. Responses of patients, relatives or
caregivers were recorded. Demographic data (age, sex) and functional
status before the stroke according to the mRS score were collected. The
main clinical features of the disease, such as stroke type (ischemic or
hemorrhagic), arterial territory if ischemic stroke, stroke etiology
according to TOAST classification (15)
if ischemic stroke, time elapsed from stroke onset to admission,
reperfusion therapies if ischemic stroke, admission to the Stroke Unit,
presence of dysphagia, presence of aphasia, length of hospitalization in
days, and cardiovascular risk factors were also recorded. History of
potential risk factors of dehydration, such as heart or renal failure,
treatment with diuretics, living alone, vomiting, diarrhea, or fever,
were recorded also.
Study Protocol
Patients were treated according to the standard local
protocol: nil per os during the first 24 h from the onset of the stroke
and intravenous hydration with saline serum (500 ml/6 h) with potassium
supplements, adjusted in selected cases when needed (heart or renal
failure history, presence of hypoglycaemia, vomiting, diarrhea, or
fever). Glucose levels were monitored periodically. After a standardized
swallowing test conducted by a trained nurse, patients started oral
hydration, and nutrition (or by nasogastric tube if severe dysphagia)
from day 2 onwards. Blood samples were obtained at admission and 3 days
after the stroke. U/C ratio was calculated. Dehydration was defined as a
blood U/C ratio >80 (10).
The study was approved by the ethics committee of Hospital de la Santa
Creu i Sant Pau. Verbal informed consent was obtained from all of the
patients or their legal representatives. A signed consent was not deemed
necessary by the committee due to the absence of a change in the
routine management of the patients and also that the data obtained were
anonymous.
Statistical Analysis
A descriptive data analysis was performed. Demographic
characteristics were reported as means and standard deviations or
percentages. NIHSS scores are reported as medians and interquartile
ranges. Differences in baseline characteristics between dehydrated and
non-dehydrated patients were compared using a chi-square (χ2) test for
categorical variables and a t-Test analysis was used to compare quantitative variables. A significant difference was defined as p
< 0.05. Univariate logistic regression models between the dependent
variable (presence of dehydration) and sex, age, subtype of stroke,
NIHSS score at admission, time from stroke onset to evaluation, presence
of heart, and renal failure, previous use of diuretics, presence of
vomiting, fever and diarrhea, presence of dysphagia and aphasia,
admission at the Stroke Unit and living alone, were investigated. In
another analysis, univariate logistic regression models were used also
between the dependent variable (unfavorable prognosis) and dehydration,
NIHSS score at admission, sex, age, subtype of stroke and admission at
the Stroke Unit, at discharge and 3 months after the stroke. A
multivariate logistic regression method was used to ascertain
independent associations between those factors with p < 0.10
from the univariate analysis. Data analysis was carried out using Stata
13.0 (StataCorp, College Station, TX) for Windows.
Results
We studied 203 patients; 160 (78.8%) with ischemic
stroke and 43 (21.2%) with hemorrhagic stroke. Their mean age was 73.4
years (SD 12.9); 51.7% of them were men. The median NIHSS at admission
was five (IQR 2–14). Patients were admitted a mean of 9.8 (SD 14) hours
after the stroke onset. All of the patients were hydrated initially
intravenously within the first 24 h of admission. From the second day
on, 168 (82.8%) were hydrated orally and 35 (17.2%) needed hydration by
nasogastric tube because of severe dysphagia or low level of
consciousness. All of the included patients were evaluated at 3 months,
164 during face-to-face interviews, and 39 by phone.
Dehydration based on the blood U/C ratio was detected in
18 patients (8.9%) at some point during the hospitalization. Nine
patients (4.5%) were dehydrated at admission and, after 3 days
follow-up, the U/C ratio was normal in eight patients and only one
remained dehydrated. The other nine patients (4.5%) were not dehydrated
at admission, but were dehydrated 3 days after the stroke.
Patients who presented dehydration were older (p = 0.019), more often women (p = 0.009) and with a higher frequency of dysphagia (p = 0.026) compared to non-dehydrated patients. No differences in other variables were found (Table 1).
From the multivariable logistic regression analysis, the variables
associated with dehydration were female sex (OR 3.62, 95% CI 1.13–11.58,
p = 0.03) and older age (OR 1.05, 95% IC 1–1.11, p = 0.048).
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